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CityLink Paratransit Service - Medical Professional Questionnaire

  1. CityLink-Logo2016-BlueAngle
  2. CityLink Paratransit Service Application

    Please use this application if you are a medical professional verifying the eligibility of a potential client.

     

    The following application must be completed by a medical professional (doctor, nurse, licensed therapist, social worker, or O&M specialist).

     

    The individual who has asked you to review and sign this application is applying for CityLink Para-transit Services. ADA para-transit service is intended ONLY for those trips that the person cannot take on the regular public bus system due to his/her disability. Please complete the assessment below. DO NOT USE ABBREVIATIONS OR CODES.

     

    You may e-mail any questions to citylink@abilenetx.gov or call 325-676-6287

  3. Professional Verification Assessments
  4. What is the nature of the disability or condition that affects the person’s ability to use the regular fixed route bus system?
    (check all that apply)
  5. General Medical Conditions*
  6. Bone & Joint Conditions*
  7. Brain/Nerves/Muscle Conditions*
  8. Heart & Circulatory Conditions*
  9. Lung & Breathing Conditions*
  10. Vision/Hearing/Speech Conditions*
  11. Developmental/Mental Conditions*
  12. Is the health condition or disability temporary?*
  13. Does the person require a personal care attendant (PCA) to accompany them on trips?*
  14. Please list credentials

  15. Leave This Blank:

  16. This field is not part of the form submission.